Provider Demographics
NPI:1073100897
Name:RIVERA, KERRY (LMSW)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:296 N MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-2550
Mailing Address - Country:US
Mailing Address - Phone:631-472-2629
Mailing Address - Fax:
Practice Address - Street 1:296 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-2550
Practice Address - Country:US
Practice Address - Phone:631-472-2629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056611-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical